LLIIFFEELLIINNEE

APPLICATION

MAIL TO:

LIFELINEINFO LINE, INC.

703 S. Main StreetSuite 211Akron OH 44311CALL:FAX:

330-762-03081-800-944-0308330-315-1392

1. HOUSEHOLD INFORMATION

SIDE 1

NAME SEX:M FDATE OF BIRTHSPOUSE/OTHER SEX:M FDATE OF BIRTHADDRESS APTCITY ZIP TOWNSHIP COUNTYHOME PHONE WORK PHONE WORK HOURS CELL PHONECOMPLEX OR BUILDING NAME

(Include if you live in an apartment, development or trailer park)

NEAREST CROSSROADKEY or LOCKBOX LOCATION

(You may want to hide your house key or place a lockbox outside and inform us of its location and combination to prevent the police from forcing entry during an emergency or false alarm.)

2. MEDICAL INFORMATION:

Please include as much information as possible.

SELF SPOUSE/OTHER

DESCRIBE YOUR MEDICAL CONDITION OR ANY DISABILITIESDO YOU TAKE A BLOOD THINNER? NAME?DO YOU USE OXYGEN?

DESCRIBE YOUR MEDICAL CONDITION OR ANY DISABILITIESDO YOU TAKE A BLOOD THINNER? NAME?DO YOU USE OXYGEN?CHECK ALL THAT APPLY:CANE QUAD CANE WALKER WHEELCHAIRELEC. SCOOTER BEDBOUND OTHER:CHECK ALL THAT APPLY:CANE QUAD CANE WALKER WHEELCHAIRELEC. SCOOTER BEDBOUND OTHER:PHYSICIAN PHONE PHYSICIAN PHONESPECIALIST PHONE SPECIALIST PHONEPREFERRED HOSPITAL PREFERRED HOSPITAL

3. PET INFORMATION

DO YOU OWN A PET? YES

NODURING THE INSTALLATION, YOUR PET(S) WILL NEEDTO BE CONFINED TO AN AREA AWAY FROM THE INSTALLER.TYPE NAME